The importance of Domestic Abuse Trauma Informed Physiotherapy: A Public Health Perspective

The Importance of Domestic Abuse Trauma-Informed Physiotherapy: A Public Health Perspective 

Author : Boitumelo Mafavuke     

Date:01/ 2025

Domestic abuse (DA) is defined as “a pattern of behaviour in any relationship that is used to gain or maintain power and control over an intimate partner” (United Nations, 2018). It is a public health issue that stems from power inequality (World Health Organization, 2013). There are four main types of domestic abuse: physical abuse, psychological abuse, financial/economic abuse, and sexual abuse. Unsurprisingly, DA is one of the leading causes of Adverse Childhood Experiences (ACEs) that negatively impact child development (Centers for Disease Control and Prevention, 2023).According to Hughes et al. (2017), experiencing ACEs such as domestic abuse increases the risk of developing health complications. For instance, it is said that the brain scan of a child who has witnessed their parent being assaulted resembles that of a soldier who has been in combat ( McCrory et al., 2011).

PREVALENCE

Both males and females can be victims or perpetrators of domestic abuse. Although females are more likely to be victims of DA related homicides (Office for National Statistics, 2020) while males are less likely to report abuse. Overall, 1 in 4 women and 1 in 6 men (World Health Organization, 2013) will experience domestic abuse in their lifetime. Despite this, it is still challenging for victims and survivors to receive adequate help. Societal perceptions of domestic abuse, a significant lack of awareness, and insufficient training among professionals contribute to  challenges of accessing support.

By the time a victim is killed, they typically  have sought help around three times (Campbell, 2002).This reflects a significant failure in recognising red flags. These missed opportunities stem from inadequate training and/or institutional victimisation (Douglas & Hines, 2011) and contribute to the substandard support victims/survivors receive. Quality support for victims and survivors can be enhanced by trauma-informed  care (National Institute for Health and Care Excellence, 2014) referred to  as trauma-informed services in this article. These include professionals who have adequate knowledge about how traumatic experiences can significantly impact treatment outcomes .Otherwise, surviving domestic abuse becomes more difficult due to barriers and insufficient support. The purpose of this article is to highlight how trauma-informed services can support victims, using physiotherapy health discipline as an example.

The significance of trauma-informed services correlates with the important role of physiotherapy in the rehabilitation of victims/survivors of domestic abuse (Baker et al., 2019).These are services offered by trauma-informed professionals. NICE (2014) guidelines state that health professionals  should be trained to be able to recognise types of domestic abuse as well as promoting disclosure through safe spaces. This contributes to the overall public health goal of combating domestic abuse. Physiotherapists are well-positioned to deliver this within their scope of practice, which includes restoring, maintaining, and promoting function (Chartered Society of Physiotherapy, 2021). In addition, the role of physiotherapy includes reducing disability (Chartered Society of Physiotherapy, 2021) including those resulting from domestic abuse. Physiotherapists use a biopsychosocial approach that focuses on a holistic therapeutic approach (Wade & Halligan, 2004) as opposed to the medical model .This further emphasises the need for physiotherapists to be domestic abuse trauma informed.

Due to the prevalence of DA, promoting trauma informed approaches early, starting from physiotherapy student recruitment, can  benefit not only successful candidates but those who choose different career paths . Thus, reinforcing the urgency of combating DA  as well as raising awareness. The physiotherapy community which includes  patients, students, and physiotherapists has a high chance of dealing with the ongoing and aftermath impact of domestic abuse in all categories.

RELEVANCE

Disclosing domestic abuse is emotionally exhausting and triggering due to reliving the experiences (Van der Kolk, 2014). It is also discouraging because of an overall lack of awareness in society, leading to the need for over-explaining and/or feelings of not being understood. Trauma-informed physiotherapists can help identify the need for intervention. It is therefore important to pay attention  to social history during patient assessment as this  benefits effective DA screening. For example, if the patient mentions that their partner has sustained injuries like a metacarpal fracture, while they present with other DA red flags, this may help identify the mechanism of injury, which can sometimes be difficult to disclose.

Raising awareness, such as through public health campaigns, has proven to be a vital tool in public education (World Health Organization, 2013).Clinicians should note that trauma-informed practices do not extend consultation time unnecessarily. On the contrary, early intervention ensures that survivors benefit from the right treatment. This includes timely referral to DA victim support agencies. One way of providing effective support includes physiotherapy awareness of the existing types of  DA, beyond surface level. Including  their specific relevance  to clinical practice. Although  literature around domestic abuse and healthcare is vast, it is often generalised. This article narrows it down  specifically to physiotherapy. However, due to limitations of the article, physiotherapy conditions resulting from the different  types of domestic abuse could not be explored extensively. Below are some examples of how trauma informed  physiotherapy is relevant  to all domestic abuse types:

Physical Abuse:

Awareness of physical abuse signs can help reduce disabilities as well as promoting effective rehabilitation. Adequate screening for red flags can help identify the need for early escalation (Roberts & Kendall-Tackett, 2003), thus reducing the overall burden on public services (National Health Service, 2018).Victims and survivors of physical abuse may present  with musculoskeletal injuries and joint stiffness that can be treated using  techniques such as manual therapy and joint mobilisation in physiotherapy (Levesque et al., 2020). Trauma-informed screening includes identifying mechanisms of injuries that do not align with the presentation of trauma or frequency of re-traumatisation. Sometimes, it could be other insidious symptoms such as marks of burns from cigarette studs (Roberts and Kendall-Tackett, 2003). Depending on how overt or covert the abuser is, symptoms can sometimes be obvious or hidden even to a well-trained eye without careful scrutiny. Research around domestic abuse being the direct cause of paediatric conditions is limited. However, using cerebral palsy as an example, it is evident that it can occur due to antenatal maternal physical trauma (Taft et al., 2002). JAMA Pediatrics (2022)  confirms that trauma during pregnancy is a risk factor for cerebral palsy in the offspring, although this research focused on unintentional trauma. As domestic abuse perpetrators often claim that assault was unintentional, this mechanism of injury in pregnancy therefore increases the risk of cerebral palsy. Direct risk to the baby also increases where there is domestic abuse (NHS, 2023) as they can also be harmed by the perpetrator  .They can also be affected if the victims/survivor is assaulted while holding them. Domestic abuse escalates when a female victim is pregnant (World Health Organization, 2013).This is also supported by NHS (2023) showing that it can lead to miscarriages, infections and injuries.

Psychological/Emotional Abuse:

Domestic abuse takes a toll on the psychological and emotional well-being of victims/survivors (American Psychiatric Association, 2023) .Sleep insomnia as well as mental health conditions are amongst injuries that survivors of DA can present with (American Psychiatric Association, 2023).Psychological abuse  is violation of   Article 1  of the Universe Declaration of human rights which states that “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood “(United Nations, 1948 ).Therefore treating everyone in contact with physiotherapy services with dignity can encourage patients dealing with the aftermath of DA to feel safe to disclose their traumatic experiences. It also prevents triggering them, while creating an environment that is relatively safe for disclosure (McGarry et al., 2014). In education, trauma informed physiotherapy can help support students who have experienced domestic abuse or those who become victims during their studies. Research shows that 42.4% of health science students including physiotherapy suffer from depression (Gabbidon et al., 2019).However, a physiotherapy student struggling psychologically due to domestic abuse may find it challenging to seek help. For example, a student struggling to attend class due to DA induced depression may find it difficult to begin the conversation around what exactly hinders them, especially if the education environment does not accommodate trauma informed support. However, disclosures can still be a challenge (Walker, 2016) even in a healthy environment. Disclosure willingness also depends on where the student is in their journey of healing, awareness as well as other factors such as cultural barriers or personality types (Walker, 2016). What physiotherapists may see as yellow flags could be a result of psychological/emotional abuse. For instance, a patient who fails to follow treatment may not be necessarily unwilling to follow instructions or deliberately non-compliant. The American Medical Association (2023) shows that domestic abuse perpetrators can interfere with their partner’s access to healthcare services, this is psychological/emotional abuse. Therefore, showing up to appointments under such circumstances is a sign of resilience and willingness to get professional support. In this case, adequate screening could help these patients reach a holistic goal of  full physical as well as psychological recovery. Similarly, one who may be physically present while frequently appearing to be absent minded,  for example asking repetitive questions or zoning out, may not be deliberately trying to cause trouble or being irresponsible. It could possibly  be due to other psychological factors such as survival mechanism like  amnesia and dissociation that  may still crop in even when there is no risk of harm (van der Kolk, 2014).

Economic/Financial Abuse:

It is extremely difficult to gain economic freedom while experiencing abuse. The presence of a healthy support system, including trauma-informed health professionals, can help individuals navigate their journey better. Due to the desire to dominate, many abusers stifle their victims to directly or indirectly disadvantage them economically and financially (Adams et al., 2008). This can include intentionally creating debts in the victim’s name as well as reckless spending to terrorise them. A student may find themselves short of travelling money during exam periods or occasionally faced with orchestrated hindrances that disrupt their studies. Similarly, a patient may also miss appointments for the same reasons, although they may not always articulate this to avoid being seen as making excuses and avoiding accountability. Economic abuse as the aftermath of surviving domestic abuse includes housing poverty as well as living conditions that contribute to poor health and longer recovery times. This also includes difficulties in purchasing as well as maintaining prescribed treatment devices such as braces and wheelchairs (Baker et al., 2019).Physiotherapists can encourage financially abused patients to use objects around the house such as furniture and towels to compensate for limited funds (Levesque et al.,2020).For example, the use of water filled bottles instead of dumbbells for resistance exercises.

Sexual Abuse:

The need for consent is significantly amplified when working with victims of domestic abuse. What may seem like harmless gestures can be harmful triggers, if they were previously used by someone who hurt them, the abuser. For instance, if they have been raped by someone who was wearing clothing that looks similar to what the physiotherapist currently treating them wears, this can become a trigger, sometimes subconsciously, unless they manage to see the connection with the clothing (van der Kolk, 2014). Although promoting same-sex physiotherapy/patient matches can be helpful, it is important to bear in mind that some patients have been sexually assaulted by  perpetrators from the same sex . Trauma-informed approaches would help where challenges are deeper than surface level. Victims of sexual abuse have an increased chance of struggling  psychologically and physically as a consequence of the abuse (Roth et al., 2017.) According to Murphy et al. (2014), 17 %  of women with pelvic floor dysfunctions have experienced sexual abuse. Physiotherapy techniques such as pelvic floor exercises may help to restore function. Physiotherapists can  couple these with  diaphragm breathing techniques to help regulate the nervous system (Cureus Journal of Medical Science, 2018).

RECOMMENDATIONS FOR DOMESTIC ABUSE TRAUMA INFORMED SERVICES 

A physiotherapy DA trauma informed public health approach could include:

1. Ensuring that survivors are aware of their holistic treatment options, including specialist domestic abuse support organisations.

2.  Conducting research on the success of  multidisciplinary DA interventions  including physiotherapy to highlight the role of physiotherapy in combating domestic abuse.

 Documentation of physiotherapy consultations where the mechanism of injury has been domestic abuse-related or where recovery has been hindered by DA . 

3. Incorporating DA awareness in physiotherapy student recruitment and orientations to promote a safe culture . 

4. Promoting trauma-informed services (for examples classrooms and clinics) to ensure that students and staff who may be victims or survivors, receive appropriate and timely intervention .According to Jones and Smith (2015),these trauma-informed services, minimise triggers and eliminate institutional abuse . 

5. Multidisciplinary antenatal consultations can also reduce paediatric conditions that stem from maternal experiences with domestic abuse. Where exposure to DA has occurred, physiotherapists can be more equipped to diagnose, refer, and reduce abuse-induced conditions.

6. Policies could be used to promote awareness as well as implementing trauma informed services. For example , documentation, may include a statement showing that the clinician took a trauma-informed approach to minimise unintentional and/or deliberate institutional abuse. Especially when there are concerns of DA.

7.  Ethical clinical practices, including the Mental Capacity Act 2005,  can be used to protect patients when perpetrators dominate consultation sessions. This promotes uninterrupted subjective assessment where there is no need for a translator. In cases where one is needed, clinicians must bear in mind that an abusive partner would not be suitable in most cases.

8. Trauma-informed educators during physiotherapy placements can also help create safe spaces for students who have experienced domestic abuse. Alterations can be made to accommodate their learning, which may be impacted by their experiences or triggered during patient consultations. Being aware of the unique challenges faced by students who have experienced domestic abuse can help promote healthy student/educator interactions.

9. Multidisciplinary teams must promote empowerment. This includes services that partner with victims and survivors by promoting dignity and autonomy. Consultations must not leave victims/survivors feeling like their voices do not matter. They should not replicate the control dynamic they already experience with their partners.

10. Allocating resources such as funding, time as well as  taking  advantage of technology to maximise adequate training and public health campaigns .

11. Maintaining healthy environments and attitudes where victims/survivors can thrive even if they choose not to disclose their experiences in the workplace or university.

IMPLEMENTATION;

Below is a successful real life case study of a student physiotherapist who was also a DA survivor on her first placement:

My placement was at a children’s hospice. I had never been to one before and was not sure about the emotional  impact of seeing children in  distressing states. It was already a rough time as I had lost my childhood friend who knew about my experiences with domestic abuse, about 3months prior to the start of placement. I felt a bit off balance, emotionally .The impact of years of experiencing domestic abuse and struggles with some professionals significantly contributed to my hypervigilance .I was also worried in case I got an overbearing educator.

During orientation,my educator asked about my learning preferences,any potential challenges,and how best to support my progress.Having interacted with him pleasantly prior to this, I took the risk to inform him about the impact of experiencing domestic abuse on my learning and information processing. I told him that I tend to have moments of “freezing” especially when I am in a situation that mimics interrogation such as being asked many questions under pressure especially while being observed .Where possible after looking at patient’s notes and discussions in the office, we positioned ourselves where we could see the patients and their parents or carers without being heard. He would ask me questions and offer his expertise before we interacted with patients. This also gave me the opportunity to gradually gain confidence in patient  assessments. With time,  I  got to feel more comfortable with him as a safe educator , as well as giving him feedback. I then became comfortable with the questions regardless of who was there because I trusted him (I did not notice the safe transition which was done with great care) and subconsciously  knew that he was not interrogating or intentionally trying to put me under pressure which would have been a trigger. I knew that he genuinely wanted me to succeed as he challenged my learning beyond expectation while simultaneously remaining a safe person to talk to if I needed support. The team also sat together every Wednesday afternoon to check on each other mentally which I found very helpful. 

Secondly, I have been  very fortunate because during my interview for a place at the university, I made it clear that domestic abuse hindered my academic progression in the past. Although I was aware that the recruiter may have chosen to use this disclosure against me. Fortunately , I was successful despite making this disclosure.

My ability to continue making  these risky disclosures  stems from the rich support I had from family, friends as well as my children’s primary school once I gathered the strength to narrate our  ordeal to them. I have learnt that this is extremely rare for many . Despite this, our journey has still been far from easy.

The above case study emphasises the need for trauma informed physiotherapy. This  benefits  everyone involved. It also shows how important support is for those impacted by DA (Adams et al., 2018). Consistency throughout interactions with victims, survivors and the general public can significantly contribute towards the vital public health goal of combating domestic abuse . 

CONCLUSION

A trauma-informed physiotherapy approach should include in-depth domestic abuse awareness and training, beginning at  undergraduate level .This would significantly reduce the need for multidisciplinary services including emergency departments  where a significant percentage of patient  visits are due to DA (Office for National Statistics, 2020). Patient recovery time can also be reduced when hindrances from continuing treatment at home reduce. In addition, during assessment, it is particularly important to note if the patient’s partner is around and ask them to leave (National Health Service, 2018) or arrange a safer assessment time. On the other hand, in education, trauma informed physiotherapy placements can offer significant support to students and avoid unintentional triggers. Intentionally creating trauma informed services also correlates with promoting safety in the work place for professionals who experience DA at home.

ETHICAL CONSIDERATIONS

Some of the ethical considerations when promoting DA trauma informed Physiotherapy include;

Treating patients with dignity, avoiding causing them further harm (CSP, 2020).

Informed consent-this involved making sure that patients with DA experience make informed consent regarding their care as well as their safety (CSP, 2020).

Confidentiality and transparency-Confidentiality remains a vital aspect of supporting victims/survivors of domestic abuse (General Data Protection Regulation, 2018). However, it is important for professionals to be transparent about the need to share information ( breaking confidentiality) in certain instances to protect vulnerable people including children.

Justice- Victims and survivors of domestic abuse need quality standard of care  that does not compromise their safety and health. In addition to this, physiotherapy services must comply with universal laws such as the Human Rights Declaration Act (United Nations,1948).

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